The perspective of school leaders on the implementation of evidence-based practices: A mixed methods study.

Background: School leaders play an integral role in the use of implementation strategies, which in turn support special education teachers in the implementation of evidence-based practices (EBPs). In this convergent mixed methods study, we explored school leaders' perceptions of the facilitators and barriers to EBP implementation, particularly for students receiving special education, as well as the importance and feasibility of 15 implementation strategies. Method: School leaders (N = 22, principals, assistant principals, school psychologists, etc.) participated in a semistructured interview that included three parts-qualitative questions, quantitative ratings of strategies' importance and feasibility, and discussion of the top three implementation strategies. Data strands were analyzed independently and then integrated to generate meta-inferences. Results: The qualitative data identified facilitators such as access to resources about the intervention (e.g., professional development) and collaboration and teamwork, while barriers centered on lack of school supports, culture/climate, and organizational factors (e.g., lack of communication). The quantitative data indicated that the implementation strategy provide ongoing consultation/coaching was rated as important and feasible. Monitor the progress of the implementation effort was rated as important but less feasible, while conduct educational meetings and change the environment were rated as feasible, but less important. Build partnerships to support implementation was rated as less important and feasible. There was convergence and divergence in mixed methods findings. Conclusion: This study underscores the critical need to increase school leaders' knowledge and skills related to implementation science to better leverage implementation strategies that address the confluence of relevant implementation determinants.

School leaders, such as principals, assistant principals, and school psychologists, are responsible for supporting special education teachers in doing interventions (e.g., through teacher training). In this study, we interviewed 22 school leaders to understand what factors support or hinder teachers in doing interventions, especially for students receiving special education. We also provided school leaders with a list of 15 strategies that may be used to support teachers, to determine which strategies school leaders think are the most important and feasible in schools. Our results indicated that it is important to train school leaders on how to move research into practice settings, such as schools. It is equally important for researchers and policymakers to understand the priorities of school leaders.

Community-based care for autistic youth: community providers' reported use of treatment practices in the United States.

Introduction: To illustrate the landscape of community-based care for autistic youth in the United States, we identified transdisciplinary psychosocial intervention practice sets that community providers report utilizing to care for this population, and examined characteristics associated with provider-reported utilization. Methods: The Usual Care for Autism Study (UCAS) Survey assessed provider demographics and provider-reported use of transdisciplinary practices for common ASD co-occurring problems: social difficulties, externalizing behaviors, and anxiety. Community practitioners (N = 701) from allied health, behavioral, education, medical, mental health and other disciplines who treat or work with autistic youth (7-22 years) participated. Results: Exploratory factor analysis yielded four factors: Consequence-Based Strategies (CBS), Cognitive-Behavioral and Therapy Strategies (CBTS), Antecedent-Based Strategies (ABS), and Teaching Strategies (TS). Providers across disciplines reported utilizing ABS more often than other sets. Providers from behavioral disciplines, with less than 4-year or Master degrees, or with more experience reported the most use of ABS, CBS and CBTS. Medical and behavioral providers reported the most use of TS. Setting and child characteristics were associated with practice set use, indicating variability by disability and client socioeconomic status. Discussion: Findings reflect the complexity and inconsistency of the service landscape for autistic youth across the U.S. Only by understanding the service landscape and predictors of practice utilization, can researchers, policymakers, provider groups, and the autistic community facilitate effective implementation strategy development and use to ultimately improve community-based care.

Preliminary effectiveness of the ACT SMART implementation toolkit: facilitating evidence-based practice implementation in community-based autism organizations.

Background: Evidence-based practice (EBP) use is varied in autism spectrum disorder community-based organizations (ASD-CBOs) in the United States. Aim: The ACT SMART Implementation Toolkit-a multi-faceted implementation strategy guiding teams through implementation phases-was pilot tested to assess its preliminary effectiveness in increasing EBP use within ASD-CBOs. Method: Six ASD-CBOs participated, and five completed all Toolkit phases. Supervisors and direct providers completed an agency assessment pre- and post-pilot reporting their use of the selected EBP. Results: Effect sizes, examining meaningful changes in reported EBP utilization from pre- to post-pilot, found small effect sizes for supervisor-reported, supervisor-report of direct provider's use, and for direct provider-reported EBP use. Conclusions: Results indicate an increase in reported EBP use post-pilot and signal potential effectiveness of the ACT SMART Toolkit to yield provider-reported behavioral changes. This is the first multi-faceted implementation strategy designed specifically for ASD-CBOs, and findings support its facilitation of EBP uptake to improve community care for autistic individuals.

Identifying Methods to Select and Tailor Implementation Strategies to Context-Specific Determinants in Child Mental Health Settings: A Scoping Review.

This scoping review describes the state of the literature regarding Implementation Strategy Mapping Methods (ISMMs) within the context of child mental health practice delivery. Goals included (a) identify and describe ISMMs addressing determinants of implementing mental health evidence-based interventions (MH-EBIs) for children and (b) describe the scope of the literature (e.g., outcomes, remaining gaps) related to identified ISMMs. Following PRISMA-ScR guidelines, 197 articles were identified. After removing 54 duplicates, 152 titles and abstracts were screened, yielding 36 articles that were screened during the full-text review. The final sample included four studies and two protocol papers (n = 6). A data charting codebook was developed a priori to capture relevant information (e.g., outcomes) and content analysis was utilized to synthesize findings. Six ISMMs were identified: innovation tournament, concept mapping, modified conjoint analysis, COAST-IS, focus group, and intervention mapping. ISMMs were successful in leading to the identification and selection of implementation strategies at participating organizations, and all ISMMs included stakeholders throughout these processes. Findings revealed the novelty of this research area and highlighted numerous areas for future investigation. Implications related to implementation, service, and client outcomes are discussed, including the possible impact of utilizing ISMMs to increase access to MH-EBIs for children receiving services in community settings. Overall, these findings contribute to our understanding of one of the five priority areas within implementation strategy research-enhancing methods used to design and tailor implementation strategies-by providing an overview of methods that may be utilized to facilitate MH-EBI implementation in child mental health care settings. Trial Registration: Not applicable. Supplementary Information: The online version contains supplementary material available at 10.1007/s43477-023-00086-3.

Evaluation of clinical assessments of social abilities for use in autism clinical trials by the autism biomarkers consortium for clinical trials.

Clinical trials in autism spectrum disorder (ASD) often rely on clinician rating scales and parent surveys to measure autism-related features and social behaviors. To aid in the selection of these assessments for future clinical trials, the Autism Biomarkers Consortium for Clinical Trials (ABC-CT) directly compared eight common instruments with respect to acquisition rates, sensitivity to group differences, equivalence across demographic sub-groups, convergent validity, and stability over a 6-week period. The sample included 280 children diagnosed with ASD (65 girls) and 119 neurotypical children (36 girls) aged from 6 to 11 years. Full scale IQ for ASD ranged from 60 to 150 and for neurotypical ranged from 86 to 150. Instruments measured clinician global assessment and autism-related behaviors, social communication abilities, adaptive function, and social withdrawal behavior. For each instrument, we examined only the scales that measured social or communication functioning. Data acquisition rates were at least 97.5% at T1 and 95.7% at T2. All scales distinguished diagnostic groups. Some scales significantly differed by participant and/or family demographic characteristics. Within the ASD group, most clinical instruments exhibited weak (≥ |0.1|) to moderate (≥ |0.4|) intercorrelations. Short-term stability was moderate (ICC: 0.5-0.75) to excellent (ICC: >0.9) within the ASD group. Variations in the degree of stability may inform viability for different contexts of use, such as identifying clinical subgroups for trials versus serving as a modifiable clinical outcome. All instruments were evaluated in terms of their advantages and potential concerns for use in clinical trials.

Usual care for youth with autism spectrum disorder: Community-based providers' reported familiarity with treatment practices.

Objective: To examine patterns and predictors of familiarity with transdisciplinary psychosocial (e.g., non-pharmacologic) practices for practitioners treating youths with autism spectrum disorder (ASD) in the United States. Method: Practitioners (n = 701) from behavioral, education, medical, and mental health backgrounds who worked with youth (ages 7-22) with ASD completed the Usual Care for Autism Survey, which assessed provider demographics and self-reported familiarity with transdisciplinary treatment practices for the most common referral problems of ASD. We examined relations between provider-, setting-, and client-level characteristics with familiarity of key groups of the treatment practices (practice sets). Practice sets were identified using exploratory factor analysis (EFA), and demographic predictors of practice subsets were examined using generalized estimating equations (GEE). Results: The EFA yielded a three-factor solution: (1) environmental modifications/antecedent strategies; (2) behavior analytic strategies; and (3) cognitive strategies, with overall familiarity ranked in this order. Medical providers indicated the least familiarity across disciplines. More experience with ASD and treating those with intellectual disabilities predicted greater familiarity with only environmental modifications/antecedent strategies and behavior analytic, but not cognitive strategies. Experience treating low SES clients predicted familiarity with environmental modification and behavior analytic strategies while experience treating high SES clients predicted familiarity with behavior analytic and cognitive strategies. Conclusion: This is the first study to identify transdisciplinary, interpretable sets of practices for treating youth with ASD based on community providers' reported familiarity. Results highlight factors associated with familiarity with practice sets, which is essential for mapping practice availability, and optimizing training and dissemination efforts for youth with ASD.

Implementation strategy mapping methods to improve autism intervention use in community settings: a study protocol.

BACKGROUND: Implementation strategies are purported to facilitate adoption and use of evidence-based practices (EBPs) across settings. The use of tailored implementation strategies may be particularly effective, as they are selected with the explicit purpose of addressing setting-specific implementation determinants. However, methods to select and tailor implementation strategies, including in community settings, remain understudied. This project will identify and describe implementation strategy mapping methods (ISMMs) from extant peer-reviewed literature and pilot test a method to match implementation strategies with determinants in low-resourced community mental health (CMH) agencies that deliver services to children on the autism spectrum. METHODS: Aim 1: A scoping review, following PRISMA guidelines, will be conducted to identify implementation strategy mapping methods (ISMMs) utilized in child mental health settings. Data extraction will identify and describe each ISMM, including identifying methodological and procedural steps, analyzing the frequency of ISMM use, and identifying outcomes measured in eligible ISMM studies. Aim 2: Using scoping review findings, select and pilot test one ISMM within five community mental health agencies in Michigan that provide services to autistic children. We will recruit five directors/agency leaders, supervisors, and direct providers at each of the eligible agencies (expected N = 25). A sequential explanatory (QUAN➔ QUAL) mixed methods design will be used. Participants will complete a demographics and client survey, as well as a needs assessment to identify implementation determinants. The impact of the ISMM on organizational readiness for change (from pre- to post-ISMM), as well as implementation outcomes of the ISMM (feasibility, acceptability, appropriateness, usability), will be examined. Semi-structured interviews will elicit stakeholder perspectives on the mapping method. DISCUSSION: The current project aims to advance our knowledge of methods for selecting, tailoring, and mapping implementation strategies to address context-specific determinants to implementation. Additionally, this project will contribute to growing science found at the intersection of implementation science and autism research by utilizing the implementation determinants framework, the CFIR, to guide data collection, analysis, and interpretation of findings. Finally, these findings may support future EBP implementation efforts within low-resourced communities, with the ultimate goal of increasing equity in access to EBPs for autistic children.

Patterns of Intervention Utilization Among School-Aged Children with Autism Spectrum Disorder: Findings from a Multi-Site Research Consortium.

When designing and interpreting results from clinical trials evaluating treatments for children on the autism spectrum, a complicating factor is that most children receive a range of concurrent treatments. Thus, it is important to better understand the types and hours of interventions that participants typically receive as part of standard of care, as well as to understand the child, family, and geographic factors that are associated with different patterns of service utilization. In this multi-site study, we interviewed 280 caregivers of 6-to-11-year-old school-aged children on the autism spectrum about the types and amounts of interventions their children received in the prior 6 weeks. Reported interventions were coded as "evidence-based practice" or "other interventions," reflecting the level of empirical support. Results indicated that children received a variety of interventions with varying levels of empirical evidence and a wide range of hours (0 to 79.3 hours/week). Children with higher autism symptom levels, living in particular states, and who identified as non-Hispanic received more evidence-based intervention hours. Higher parental education level related to more hours of other interventions. Children who were younger, had lower cognitive ability, and with higher autism symptom levels received a greater variety of interventions overall. Thus, based on our findings, it would seem prudent when designing clinical trials to take into consideration a variety of factors including autism symptom levels, age, cognitive ability, ethnicity, parent education and geographic location. Future research should continue to investigate the ethnic, racial, and socioeconomic influences on school-aged intervention services.

Short report: Call to action for autism clinicians in response to anti-Black racism.

LAY ABSTRACT: Black autistic people experience anti-Black racism when interacting with service systems and the clinicians in those systems. In this article, we describe the various steps families take to get services and how anti-Black racism makes that process even harder. We discuss research that shows the negative effects of anti-Black racism in autism assessment, treatment, and quality of care. We then provide five recommendations that clinicians should follow to reduce anti-Black racism in the autism field: (1) find Black autistic people and listen to their opinions about your organization, (2) always keep learning about how your profession promotes anti-Black racism, (3) recognize that the process of a clinician learning to be culturally humble takes time and is never "complete," (4) pay attention to all of the steps that families must take to receive autism services and how these steps are even harder for Black individuals, and (5) advocate for your organization to make systems-level changes in their policies and procedures.

Facilitators and barriers to the utilization of the ACT SMART Implementation Toolkit in community-based organizations: a qualitative study.

BACKGROUND: Evidence-based practices (EBPs) have been shown to improve behavioral and mental health outcomes for children diagnosed with autism spectrum disorder (ASD). Research suggests that the use of these practices in community-based organizations is varied; however, the utilization of implementation guides may bridge the gap between research and practice. The Autism Community Toolkit: Systems to Measure and Adopt Research-Based Treatments (ACT SMART) Implementation Toolkit is a web-based implementation toolkit developed to guide organization-based implementation teams through EBP identification, adoption, implementation, and sustainment in ASD community-based organizations. METHODS: This study examined the facilitators and barriers (collectively termed "determinants") to the utilization of this toolkit, based on the perspectives of implementation teams at six ASD community-based organizations. Two independent coders utilized the adapted EPIS framework and the Technology Acceptance Model 3 to guide qualitative thematic analyses of semi-structured interviews with implementation teams. RESULTS: Salient facilitators (e.g., facilitation teams, facilitation meetings, phase-specific activities) and barriers (e.g., website issues, perceived lack of ease of use of the website, perceived lack of resources, inner context factors) were identified, highlighting key determinants to the utilization of this toolkit. Additionally, frequent determinants and determinants that differed across adapted EPIS phases of the toolkit were noted. Finally, analyses highlighted two themes: (a) Inner Context Determinants to use of the toolkit (e.g., funding) and (b) Innovation Determinants (e.g., all website-related factors), indicating an interaction between the two models utilized to guide study analyses. CONCLUSIONS: Findings highlighted several factors that facilitated the utilization of this implementation guide. Additionally, findings identified key areas for improvement for future iterations of the ACT SMART Implementation Toolkit. Importantly, these results may inform the development, refinement, and utilization of implementation guides with the aim of increasing the uptake of EBPs in community-based organizations providing services to children with ASD and their families. Finally, these findings contribute to the implementation science literature by illustrating the joint use of the EPIS framework and Technology Acceptance Model 3 to evaluate the implementation of a web-based toolkit within community-based organizations.

Implementation-as-Usual in Community-Based Organizations Providing Specialized Services to Individuals with Autism Spectrum Disorder: A Mixed Methods Study.

Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder. ASD community-based organizations (ASD-CBOs) underutilize or inconsistently utilize evidence-based practices (ASD-EBPs) despite numerous available EBPs to treat ASD. Nonetheless, ASD-CBOs implement changes to practices regularly. Understanding ASD-CBO's implementation-as-usual (IAU) processes may assist to develop strategies to facilitate ASD-EBP adoption, implementation and sustainment. A convergent mixed methods (quan + QUAL) design was utilized. Twenty ASD-CBO agency leaders (ALs) and 26 direct providers (DPs), from 21 ASD-CBOs, completed the Autism Model of Implementation Survey Battery, including demographic and agency IAU process questions. Surveys were analyzed through descriptive and content analyses. A subset of 10 ALs provided qualitative interview data that were analyzed using coding, consensus and comparison methods to allow for a more comprehensive understanding of the IAU process within their ASD-CBOs. Quantitative analyses and qualitative coding were merged utilizing a joint display and compared. Results suggest that the IAU process follows some phases identified in the Exploration, Preparation, Implementation, Sustainment (EPIS) framework but were conducted in an informal manner-lacking specificity, structure and consistency across and within ASD-CBOs. Moreover, data suggest adding a specific adoption decision phase to the framework. Nonetheless, most ALs felt previous implementation efforts were successful. IAU processes were explored to determine whether the implementation process may be an area for intervention to increase ASD-EBP utilization in ASD-CBOs. Developing a systematized implementation process may facilitate broader utilization of high quality ASD-EBPs within usual care settings, and ultimately improve the quality of life for individuals with ASD and their families.

Community-based implementation strategy use and satisfaction: A mixed-methods approach to using the ERIC compilation for organizations serving children on the autism spectrum.

Background: Despite efforts to use standardized taxonomy and research reporting, documenting implementation strategies utilized in community settings remains challenging. This case study demonstrates a practical approach to gather use of and satisfaction with implementation strategies utilized within community-based sites to understand community providers' perspectives of implementing an early intensive behavioral intervention (EIBI) for children on the autism spectrum across different settings. Methods: Using a sequential explanatory mixed-methods design, survey and interview data were collected from directors/supervisors and direct providers (n = 26) across three sites (one university and two community-based replication sites). The Implementation Strategies and Satisfaction Survey (ISSS) was administered to identify staff-reported implementation strategy use and satisfaction. Informed by quantitative results, follow-up semi-structured interviews were conducted with a subsample (n = 13) to further understand staff experiences with endorsed implementation strategies and elicit recommendations for future efforts. Results: Survey results were used to demonstrate frequencies of implementation strategies endorsed by site and role. Overall, staff felt satisfied with implementation strategies used within their agencies. Content analysis of qualitative data revealed three salient themes related to implementation strategy use-context, communication, and successes and challenges-providing in-depth detail on how strategies were utilized, and strategy effectiveness based on community providers' experiences. Recommendations were also elicited to improve strategy use within "broader" community settings. Conclusions: The project demonstrated a practical approach to identifying and evaluating implementation strategies used within sites delivering autism services. Reporting implementation strategies using the ISSS can provide insight into community providers' perspectives and satisfaction with agency implementation strategy use that can generate more relevant and responsive strategies to address barriers in community settings. Plain language abstract Examining community providers' preferences and experiences with implementation strategies used to facilitate evidence-based practice uptake can broaden our understanding of what, how, and why implementation strategies work in community-based settings ( Chaudoir et al., 2013; Leeman et al., 2017; Proctor et al., 2013). Such efforts have great potential to tailor implementation strategies to address barriers/facilitators typically found in community-based settings.This case study demonstrates a practical approach using mixed methodology to: (a) gather self-reported use of and satisfaction with implementation strategies to understand community providers' perspectives of implementation strategy success. Using a new survey, the Implementation Strategies and Satisfaction Survey (ISSS) conjoined with interviews, the study demonstrated a practical approach using standardized language to report strategies used in one university-based site and two community-based replication sites that deliver an early intensive behavioral intervention (EIBI) for children on the autism spectrum. This paper contributes to one of the five priorities to enhance public health impact-improve tracking and reporting of implementation strategies utilized when translating research into practice ( Dingfelder & Mandell, 2011; Powell et al., 2019; Stahmer et al., 2019). This approach emphasizes the importance of understanding context (e.g., community organizations providing services to children on the autism spectrum) to develop strategies that work better for EIBI implementation and scale-up. Understanding community provider's preferences and experiences with implementation strategies can support use of implementation strategies that better fit usual care contexts, with the ultimate goal of improving implementation practice in community-based settings.